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a APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES WELI ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202ZC (209) "&,U20 OWREFUNDABLE FINWF IMIREt 1 YEAR FROM DATE ISSUED `^1 (CampMu IN 111'iM.hl APPJCA710N IS IIFFF BY MADE TO 714E SAN JOAOUIN COUNTY FOR A P%Fl MfT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED. TINS APPLICATION IB MADE IN COMPLIANCE W114 SAN JOAQUIN COUNTY DEVELOPMENT TrTLE• C14APTER S• 1115-3 ANO THE 6TMIDAROS OF SAN JOAQUIN COUNTY PUIKI : HEALTII SERVICES, ENNRONMENTAL HEALTH DP.na1ON. JOB ADDRESSIOM ADN/ G ! - GI iP - ic7 CITYi /.�/7[%- PA IZETA •it OWFIEIrS NAME ] [fJ:: �cTi✓.I•Ti57u [. `i G'[f.• AD01as:iYli-�s� /A� t:�!- (v Y! COMMCTOR�6._' ,ot— L�CJ %� ' AODMOD '•'7O. Cit' d.3% "I"Az-u-A Oct '2162-'I%'2 PHONES Ire j.2 -3:L. TjJ T4 RVS COHTMCTOR _.O Ja,L' d7[tZ/ Lim �^gf.0 . A.L'L° AOOEE ' -•' L1C/�fJ.i�C_i 1AtOHE /!/4.J iG) i� TYRE Or WELLRUMP. ® HEW WELL ❑ REPIACEMETMT WELL ❑ MONROMM WELL • ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ❑ N. ❑ R40411 H.F. DEPTH PUMP SET FT.FI WATER LEVEL O I.MP rTYPE OF Fl/I ❑ OUTOr-SERVICE WELL ❑ OEOPHNOICAL WELLS LK11L SONNG t D DESiR1ICTR)IM: IR441IV-m VFe GVR.IR{ '-m oggmwmAIlom7 A mr INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WEIL fXCAVATION cj 1p DIA. OF CONDUCTOR CASINO O ❑ DOMEaTICMpVATE ® ORAVEL PACK/MZE TYPE OF CA91N0/lT[ELJPVU_ L4 'G Z- OLA. OF WELL CASINO / p �1 ❑�,,P_U�SLIGMUMCtPAI ❑O19VEN wrl14OF Gmur BE At Cid 4 ,_, St•'fC1F1CA110N -56W>E&4&&7�I&2ta&4&&741 fR MAIIONIAO ❑ OTHER OROITT SEAL M9TA11EO RY�Ig OROUT BRAND NAME f ❑ moworaNO /0/0 / GROIN SEAL FUMFED: W Yr ❑ N. CONCRETE PEDESTAL. Bl' DRILLER: ❑ Yr ®N.5 RO APFII. D4TH LOCKING CHESTER 80 XTSTVVE PIPE 'A Po" c. S NMOPOMD CON21RUCTfGN/DISLLMG METNOO-- LAUD ROTARY ✓ AIR ROTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT 1 HAVE PIiPAREO TMS AFPUCAT" AND THAT THE WClW WRL SE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY Of"NANCER. STATE LAWS, AND RUBS AND RIFOLILATIOfMS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LJCPMO AGENT'S SKINATURE CERTIFIES THE FOLLONfMgr 'I CERTIFY 114AT IN THE PFWORMANCE OF TIIE W'GFIC TOR WHICH IRIS P'EIYIIIT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT To W0Mt'MAN'7 COMPMOATt" LAWS OF CALIFORNIA,' CONTRACTOR'S HIRyO OR SUB-CONTRACTINO SIGNATURE CTRTSTE7 THE FOLLOWING! ' 1 CERfIFY THAT M THE P"WORPRANCE OF THE WOI7C FOR WHICH THIS PU MTT 19 ISSUED, I @HALL EMPLOY PERBONa SURTFCT TO VIORIOr1AN'S COMPST/@ATION LAWS OF CAI"RHIA_' THE APPLICANT MUST CALL 24 HOURS SE ADVANct FOR ALL RSOLIAIM INSP "ONG AT 120M 400-7427. COMPLETE DRAvwM AT IOVRA AREA PROV Mo . & ..0 Ott._ .cl f ! Ap /d f'i PLOT PLAN 10'. t. G-1.1 7..I. t 1. NAMES OF STREETS OR ROADS NEAREST 70 OR BOUND040 THE PPIOPERrY. •, LOCATION OF HOUSE SEWAGE DISPOSAL STSTTEM OR PROPOSED 2. OUTLINE Of THE P"OFFKTY, GIVSIO DIMN MMI AND HUM" DIRECTION. EXPANSION Of SEWAGE DISPOSAL SYSTEMS, 7. DIMENSIONED OUTU MFS AHO LOCATION Of ALL "ll"IMG AND FROFl1Iwo S. LOCATION OF WELl7 Wrn*N RAMS OF ONE HUNDMO, FIFTY FT. STRLICTUREB, SMCLUDIM COV ETGO AREAS SUCH All rATIO9. OfMIVEWAYE, AND WALKS, ON THE PMKRTY OR ADJOINfNO PIOPERTY, : i ' •t .... .. .. ., . v ..... ...j... ..... �.. .. APFW+tlen A~lr 1"_ O•su/ lop—do" Sy_ D..tnmik" I ow un 9y T31 loLAvry /- ACCOUNTING ONLY: I AIDS R come FEE Ilio AMOUNT Rt9uSTIM Pub H@aM Serv. - Ermro. 173 (1197) Ov. OfFAATMENT W( G``N,`T ^G` d�.•• (a}(/'J� _ Ams a.►..��... By two IVC 1 It A ► ECKt ASH RIICSVEO 7Y DATE v3'0 $ -z,L f INVOICE V a